21 COGNITIVEDISORDERS 529
PROMOTING ADEQUATE SLEEP
AND PROPER NUTRITION,
HYGIENE, AND ACTIVITY
Clients require assistance to meet basic physiologic
needs. The nurse monitors food and fluid intake to
ensure adequacy. Clients may eat poorly because of
limited appetite or distraction at mealtime. The nurse
addresses this problem by providing foods clients like,
sitting with clients at meals to provide cues to con-
tinue eating, having nutritious snacks available when-
ever clients are hungry, and minimizing noise and
undue distraction at mealtimes. Clients who have dif-
ficulty manipulating utensils may be unable to cut
meat or other foods into bite-size pieces. The food
should be cut up when it is prepared, not in front
of clients, to deflect attention from their inability to
do so. Food that can be eaten without utensils or
finger foods such as sandwiches and fresh fruit may
be best.
In contrast, clients may eat too much, even in-
gesting inedible items. Providing low-calorie snacks,
such as carrot and celery sticks, can satisfy the desire
to chew and eat without unnecessary weight gain.
Enteral nutrition often becomes necessary when
dementia is most severe, although not all families
choose to use tube feedings.
Adequate intake of fluids and food is also neces-
sary for proper elimination. Clients may fail to re-
spond to cues indicating constipation, so the nurse or
caregiver monitors the client’s bowel elimination pat-
terns and intervenes with increased fluids and fiber
or prompts as needed. Urinary elimination can be-
come a problem if clients do not respond to the urge
to void or are incontinent. Reminders to urinate may
be helpful when clients are still continent but not ini-
tiating use of the bathroom. Sanitary pads can ad-
dress dribbling or stress incontinence; adult diapers,
rather than indwelling catheters, are indicated for
incontinence. The nurse checks disposable pads and
diapers frequently and changes soiled items promptly
to avoid infection, skin irritation, and unpleasant
odors. It is also important to provide good hygiene to
minimize these risks.
Balance between rest and activity is an essential
component of the daily routine. Mild physical activ-
ity such as walking promotes physical health but is
not a cognitive challenge. Daily physical activity also
helps clients to sleep at night. The nurse provides rest
periods so clients can conserve and regain energy,
but extensive daytime napping may interfere with
nighttime sleep. The nurse encourages clients to en-
gage in physical activity because they may not initi-
ate such activities independently; many clients tend
to become sedentary as cognitive abilities diminish.
Clients often are quite willing to participate in phys-
ical activities but cannot initiate, plan, or carry out
those activities without assistance.STRUCTURING THE ENVIRONMENT
AND ROUTINE
A structured environment and established routines
can reassure clients with dementia. Familiar sur-
roundings and routines help to eliminate some con-
fusion and frustration from memory loss. Providing
routines and structure, however, does not mean forc-
ing clients to conform to the structure of the setting
or routines that other people determine. Rather than
impose new structure, the nurse encourages clients
to follow their usual routine and habits of bathing
and dressing (Engelman et al., 2002). For example, it
is important to know whether a client prefers a tub
bath or shower and washes at night or in the morn-
ing and to include those preferences in the client’s
care. Research has shown that attempting to change
the dressing behavior of clients may result in physi-
cal aggression as clients make ineffective attempts to
resist unwanted changes (Allen-Burge et al., 1999).
Monitoring response to daily routines and making
needed adjustments are important aspects of care.
The nurse needs to monitor and manage the
client’s tolerance of stimulation. Generally clients
can tolerate less stimulation when they are fatigued,
hungry, or stressed. Also, with the progression of
dementia, tolerance for environmental stimuli de-
creases. As this tolerance diminishes, clients need a
quieter environment with fewer people and less noise
or distraction.PROVIDING EMOTIONAL SUPPORT
The therapeutic relationship between client and nurse
involves “empathic caring” (Williams & Tappen, 1999),
which includes being kind, respectful, calm, and re-
assuring and paying attention to the client. Nurses
use these same qualities with many different clients
in various settings. In most situations, clients give
positive feedback to the nurse or caregiver, but clients
with dementia often seem to ignore the nurse’s efforts
and may even respond with negative behavior such
as anger or suspicion. This makes it more difficult
for the nurse or caregiver to sustain caring behavior.
Nevertheless, nurses and caregivers must maintain
all the qualities of the therapeutic relationship even
when clients do not seem to respond.
Because of their disorientation and memory loss,
clients with dementia often become anxious and re-
quire much patience and reassurance (Williams &
Tappen, 1999). The nurse can convey reassurance by
approaching the client in a calm, supportive manner
as if nurse and client are a team—a “we can do it